1. Background

Due to an increase of international marriages and drastic influx of foreign workers and international students since 2000, the proportion of foreigners in the total population of Korea has steadily increased, reaching 3.4% of the total population in 2017. Among foreigners staying in Korea, marriage immigrants account for the second highest percentage after migrant workers. Around the 82% of the total marriage immigrants are women, because the dominant type of international marriage in Korea is the union of woman from a lower income country and Korean man. They were known to choose to immigrate to Korean due to motivations such as the need to support family in their home countries, expansion of employment opportunities, and desire for a better life and life satisfaction [1]. According to the results of the National Survey of Multicultural Families 2015, the first ranked item among the supporting services which marriage immigrants want to receive was job training and job placement. Especially the group of immigrants who have lived in Korea for a long period over 10 years had showed the highest needs of employment. As reflected in this situation, the employment rate of marriage immigrant women has risen steadily over the past decade, and 59.5% of them were in employment in 2015, far exceeding the employment rate of 49.9% of Korean women [2].

As the history of international marriage gets longer in Korea, many female marriage immigrants have passed the initial adaptation phase and entered into the real integrative adaptation phase. In order for immigrants to become stable members of society, participating to economic activities in the society they have moved into is essential. Since the income generated by working enables them to make various consumption activities for social adaptation, participation in economic activities contributes to improving the adaptation level of immigrants and lowering the risk of social exclusion derived from poverty [3]. However, despite the increased participation of female immigrants in economic activities and the improvement of household income of multicultural families, the proportion of multicultural households with the average monthly household income of less than 3 million won in 2015 is 63.0%, showing that they are still economically vulnerable. In addition, most of marriage immigrants are engaged in low-skilled jobs such as simple labor, have low social status, receive lower wages and are more exposed to poor working conditions compared to Korean workers [2].

The poor working conditions and low socioeconomic status of working married immigrant women serve as social determinants of deteriorating health. In addition, low accessibility to healthcare services, weak social networks and social supports, vulnerable health behaviors, high levels of stress, and exposure to dangerous environments are known to be the determinants that adversely affect immigrants' health [4]. Female migrant workers in Korea have been reported to be suffering from frequent gender-based discrimination and violence at working place, and immigrants who experienced such social discrimination and violence have been found to have poor physical and mental health status [5, 6]. These findings suggest that working married immigrant women may also be exposed to similar risks. Moreover, they are faced with the task of adapting to the new society and culture since they are not only foreign workers but also immigrants who have settled in Korea as spouse of Korean. It is known that immigrants who have experienced the adaptation stress shows high risk of various physical and mental health problems [5]. In addition, as women, they experience pregnancy and childbirth that cause the physical changes and role transitions in Korea. Pregnancy-related health problems such as anemia, gynecological disease, and toxemia of pregnancy as well as depression, conflicts, and stress are common in marriage immigrant women [7]. These health problems increase the needs for healthcare services naturally.

Despite the high healthcare needs of marriage immigrant women, they do not utilize sufficient healthcare services for various reasons, such as difficulty in communicating with medical staffs, unfamiliarity with the Korean health system, distant health facilities and inconvenient transportation, no person available to care for their child, the burden of medical costs due to poor economic status, and absence of health insurance [8, 9]. As described above, in the case of individuals do not receive healthcare services required to avoid negative health consequences as described above, it is defined as unmet healthcare needs [10]. Unmet healthcare needs are important for assessing coverage of the national health care system and used as a proxy indicator of accessibility to healthcare. To achieve the goal of the Korean National Health Plan 2020, which is to eliminate the health disparities among different groups of the population and to improve health equity of the society, the efforts to address the causes of unmet healthcare needs of marriage immigrants should be accompanied. In previous studies, demographic characteristics such as age, education level, employment status, country of origin; and factors enable to utilize healthcare facilities such as residence area, period of residence in Korea, household income, enrollment of health insurance, type of household, Korean proficiency, experience of social discrimination were found to affect unmet healthcare needs of marriage immigrant women. In addition, self-rated health status and experience of disease within past two weeks that directly related to healthcare needs have been shown to have a significant effect [11, 12]. One of the affecting factors mentioned above, unemployment status is generally known to be the main cause of increasing unmet healthcare needs since it decreases the income level and lowers the ability to pay for medical costs. However, in the previous studies on married immigrant women in Korea, unmet healthcare needs among employed persons were consistently higher than unemployed. These results imply the possibility that although the participation of immigrant women in economic activities improves the ability to pay for healthcare services, other factors related to economic activities increase the healthcare needs or hinder the use of healthcare services. Kim & Lee [12] attributed higher unmet healthcare needs in working married immigrant women to the time constraints on the healthcare utilization due to fixed working hours, but this interpretation did not supported by additional analyses considering occupational characteristics of participants. A prior study which analyzed the factors affecting unmet healthcare needs in wage workers in Korea showed that employment status and working hours were significant related factors, suggesting that occupational characteristics are related to unmet healthcare needs [13].

Social investment to deal with unmet healthcare needs of working married immigrants is an important social task because it can reduce health disparities in Korean society. Through this, we can improve the entire population's health status in the long term by lowering unmet healthcare needs of vulnerable people. Although many previous studies have focused on married immigrant women's health problems and their use of healthcare services, working married immigrant women, who may be a more vulnerable than those who are not working, relatively have been received little attention. Therefore, this study aimed to contribute to improving their healthcare accessibility and health status by investigating the current status of unmet healthcare needs of working married immigrant women and elucidating the effects of various characteristics including occupational characteristics on unmet healthcare needs.

2. Purpose of the Study

The purpose of this study was to investigate the characteristics of working married immigrant women and the level of unmet healthcare needs and to elucidate the factors affecting their unmet healthcare needs. Through this research, we attempt to provide a basis for policy development to secure the healthcare accessibility of working married immigrant women in Korea. The specific objectives of this study are as follows:

1. Study Design

This study was designed as descriptive, cross-sectional study that analyzing secondary data from the National Survey of Multicultural Families 2015 conducted by the Ministry of Gender Equality & Family and Statistics Korea.

2. Data Source and Study Population

This study used the National Survey of Multicultural Families 2015 (hereafter, NSMF), which is a nationally representative survey on multicultural families. It is conducted in every three years based on the Multicultural Family Support Act (Act No. 8937, Mar. 21, 2008) since 2009. The target population of NSMF was household member of multicultural family (i.e. marriage immigrants, their spouse, and offspring) and naturalized non-marriage migrants residing in Korea during the survey period. 544 trained investigators directly visited the households and surveyed through in-person interview from July 22 to August 18, 2015. The sample of NSMF was selected through two-stage sampling process. In the first stage, Statistics Korea selected 850 district from the 3,470 total administrative district in Korea by clustered systematic sampling, using the registration data (alien registration data, family-relationship registration data, and resident registration data). Then, in the second stage, multicultural households registered in 850 district were selected by stratified systematic sampling. The 17,879 households out of total 26,098 household participated in the survey, and the response rate was 65.8%[2].

The subjects of this study are female marriage immigrants who are currently working in Korea. Out of 17,109 marriage immigrants and naturalized people who were surveyed, male (2,702 persons), unmarried (132 persons), and persons who did not answer to the item measuring unmet healthcare needs (318 persons) were excluded. In addition, people aged 65 years or more (321 persons) were excluded considering possible working age (15 to 64 years), and people who did not currently working (5,869 persons) were also excluded. Thus, a total of 8,142 persons were finalized as the subjects of this study.

3. Conceptual Framework

Based on Andersen's health behavior model, which explains the use of healthcare services, the conceptual framework of this study was constructed. Assuming that the behavioral characteristics of individuals influence the use of healthcare services, Andersen classified the affecting factors into three categories. Predisposing factors include demographic characteristics (i.e. gender and age), social structure (i.e. education level and occupation), and individuals' beliefs, values or knowledge about disease or the use of health care services. Enabling factors refer to the means of accessing and using healthcare services, and include the resources of individuals or families (i.e. income, health insurance, and usual source of care) and community resources (i.e. healthcare workers and facilities). The need for healthcare is a factor directly related to the healthcare service utilization, and includes the subjective health status perceived by individual and clinical health needs assessed by healthcare professionals [14]. This model was first published in the 1960s, has been revised and steadily used in various researches studying healthcare accessibility of vulnerable groups such as homeless and immigrants. However, since the model does not sufficiently embrace the immigrants' characteristics that could influence to their behavior of healthcare utilization, a research model including factors like duration of residence, host language proficiency, immigrant generation status, age at immigration, and legal status is needed [15]. Therefore, in this study, a theoretical framework is proposed to reflect working married immigrant women's characteristics by dividing Andersen's three categorized factors into general factors, immigrant-specific factors, and labor-specific factors (Figure 1).

Figure 1 Conceptual framework for the study. Click for larger image

4. Measures

5. Ethical Considerations

The NSMF is conducted by performing education and training for survey investigators based on survey guidelines prior to data collection. In particular, it is emphasized that the interviewers should not disclose the information learned during the survey process or use them for other purposes. In addition, the survey should be conducted after sufficiently explaining that the survey results are used for statistical purposes only and confidentiality is guaranteed. The raw data of NSMF are disclosing to the public through the website of the Micro Data Integrated Service (MDIS) of the Statistics Korea. Since personally identifiable information is deleted from the data provided, the anonymity and confidentiality of participants are guaranteed. Researchers obtained the data following procedures posted at the web-site, and this study was conducted after gaining the approval of the Institutional Review Board of the university to which the researchers belong (IRB No. E1705/003-005).

6. Statistical Analysis

Frequency analysis was conducted to understand the general and occupational characteristics of working married immigrant women. To determine the unadjusted relationship between predictors and outcome variable, χ² test was used. Logistic regression analysis was applied to determine the factors independently associated with unmet healthcare needs of working married immigrant women. All statistical analysis were performed using STATA/IC version 14.0 and the significance level was set at 95%.

1. General and Occupational Characteristics of Subjects

A total of 8,142 working married immigrant women aged 19 to 64 years were analyzed in this study. Their general characteristics and occupational characteristics are presented in Table 1. As for the age, 80.8% of participants were in the 25 to 49 age group. 10.4% of subjects were previously married, and 31.5% lived with preschooler. Regarding the level of education, the percentage of high school graduate was the highest (43.8%), followed by college graduate or higher (28.6%) and middle school graduate or lower (27.6%). The largest number of subjects came from China (25.3%), followed by Vietnam (18.9%), Korean-Chinese (16.0%), the Philippines (10.1%) and Japan (8.8%). Over half of subjects 50.2%) were long-term residents who lived in Korea more than 10 years. The average household income was in the order of 3 million won or more (44.9%), 2~2.99 million won (27.9%), 1~1.99 million won (22.1%), and less than 1 million won (5.1%). Much more subjects were lived in urban area (61.7%) than rural area (38.3%). 66.4% of subjects reported that having helpful social relationship, and 42.3% experienced social discrimination. The level of Korean proficiency was in the order of the high level (52.5%), medium level (40.1%), and low level (7.4%). The highest percentage of respondents assessed their self-rated health status as good (63.2%), and 37.5% answered that they experienced grief or desperation lasting for two weeks within the past year.

Table 1 General Characteristics of the Subjects (N=8,142) Click for larger image

Regarding the occupations, more than half of subjects were manual workers (57.6%), followed by service · sales workers (26.6%) and professional · office workers (15.8%). Among manual workers, the percentages of simple labor workers (31.2%) and equipment/machinery operator · assembly workers (14.5%) took relatively high proportion. As for employment status, wage workers accounted for the highest percentage (82.7%), followed by unpaid family workers (9.5%) and self-employed (7.8%). Among wage workers, the percentage of regular workers was highest (33.4%), followed by temporary workers (32.8%), and daily workers (16.5%). For the average working hour per week, the majority of subjects (54.5%) were working 40 hours or less per week, 28.9% working 41 to 59 hours, and 16.7% working 60 hours or more (Table 2).

Table 2 Occupational Characteristics of the Subjects (N=8,142) Click for larger image

2. The Current Status of Unmet Healthcare Needs of Subjects

Overall, 11.6% of working married immigrant women reported having experienced unmet healthcare needs within the past year (Table 3). Among predisposing factors, there were significant differences in unmet healthcare needs according to the marital status, period of residence in Korea, and employment status. The respondents previously married (p<.001), those whose residence period in Korea was shorter (p=.033), and those who were self-employed or wage workers compared to unpaid family workers more experienced unmet healthcare needs (p=.005). As for all enabling factors, the statistical differences in unmet healthcare needs were found. The level of unmet healthcare needs was higher when the average monthly household income was lower (p<.001), subjects who are living in urban area (p=.019), having no helpful social relationship (p<.001), and experienced social discrimination (p<.001) showed higher unmet healthcare needs than their counterparts. In addition, unmet healthcare needs was higher in the group with a medium or low Korean proficiency compared to the group with high Korean proficiency (p<.001). The longer the average working hours, the higher the unmet healthcare needs (p=.048). According to need factors, bad self-rated health status (p<.001) and experience of grief or desperation lasting 2 weeks (p<.001) were also significantly associated with high unmet healthcare needs.

Table 3 Affecting Factors Unmet Healthcare Needs of Working Married Immigrant Women Click for larger image

3. Factors Affecting Unmet Healthcare Needs of Working Married Immigrant Women

In the multivariate analysis, factors independently associated with an unmet healthcare needs for working married immigrant women included existence of preschooler, country of origin, period of residence in Korea, monthly household income, helpful social relationship, experience of social discrimination, Korean proficiency, working hour per week, self-rated health status, and experience of grief and desperation (Table 3). Marriage immigrant women who had preschool child more likely to have experienced an unmet healthcare needs (OR=1.22, 95% CI=1.02~1.46). Compared to the subjects from Vietnam, those from Japan (OR=2.55, 95% CI=1.81~3.58), China (OR=1.44, 95% CI=1.12~1.85), Korean-Chinese (OR=1.44, 95% CI=1.06~1.94), and from other countries (95% OR=1.32, CI=1.03~1.69) were more likely to experience unmet healthcare needs. Compared to the period of residence of 1 to 5 years, the likelihood of experiencing unmet healthcare needs was 0.66 times lower when the period of residence in Korea was 6 to 10 years (p<.001), and 0.51 times lower when the period of residence in Korea was 11 years or longer (p=.001). Compared to the group with the monthly income of 3 million won or more, the lower the monthly household income, the higher the likelihood of unmet healthcare needs (OR=1.22, 95% CI=1.01~1.47 for 2~2.99 million won; OR=1.66, 95% CI=1.35~2.04 for 1~1.99 million won; OR=2.24, 95% CI=1.65~3.03 for less than 1 million won). The person with helpful social relationships was 0.78 times less likely to have unmet healthcare needs (p<.001), on the other hand, the person experienced social discrimination was 1.78 times more likely to have unmet healthcare needs than their counterparts (p<.001). The group with medium-level Korean proficiency was 1.41 times more likely to experience unmet healthcare needs than the group with high-level Korean proficiency (p<.001). The longer working hours (OR=1.23, 95% CI=1.03~1.45 for 41 to 59 hours; OR=1.37, 95% CI=1.10~1.69 for 60 hours or more) were associated with high risk of unmet healthcare needs. Subject with bad (OR=4.72, 95% CI=3.77~5.90) and fair (OR=1.94, 95% CI=1.64~2.29) health status were more likely to experience unmet healthcare needs than those who with good health status. The person who experienced grief or desperation was 2.82 times more likely to have unmet healthcare needs than those who without any experience (p<.001).